Reporting to the Utilization Management leadership, the Referral UM Coordinator plays a pivotal role in furnishing essential clerical support and aiding the clinical team within the UM department on a day-to-day basis. This pivotal position assumes responsibility for efficiently handling a substantial volume of prior authorization requests.
Requirements
- Accurately processes medical authorizations according to company/department policies and procedures.
- General knowledge of CPT and ICD9/ICD10 and HCPCS codes as it relates to the processing of medical billing and/or authorizations.
- Familiar with medical terminology as it relates to IPA's, PPO's and HMO's
- Ability to interpret and communicate complex contract or benefit language.
- Strong problem-solving abilities.
- Composes basic letters, faxes, & emails which are sent to various providers as it relates to authorizations.
- Works collaboratively with internal departments to obtain information or documentation required to accurately process authorizations.
- Verifies all information in EZCAP is correct and makes changes/ updates as necessary.
- Answers all authorization inquiries in a professional and positive manner ensuring that all information given is accurate.
- Conducts calls to providers, facilities, vendors for additional information on authorization requests, as needed.
- Place calls to members and providers regarding authorization outcome within the necessary notification timeframe.
- Monitors emails and/or faxes daily and appropriately distributes incoming faxed requests.
- Monitors the determination and notification Turn-Around Timeframes (TAT) and managing daily workload according to TAT requirements.
- Troubleshoot calls from members, providers, health plans, hospitals, and other business affiliates to facilitate a seamless UM service.
- Handles UM Department's mailing distribution and assisting in mail room, which may require scanning and inputting data in accordance with department practice.
- Implements patient discharge plans delegated by Inpatient UM Nurse by coordinating with home care agencies, post-acute care facilities, durable medical equipment companies, transportation agencies and others as indicated.
- Attentive to detail, accurate, thorough, and persistent in following through to completion of all activities, demonstrating initiative for completing work assignments.
- Excellent communication skills; able to read, write, and speak articulately, using established channels of communication and reporting relationships within the organization.
- Ability to communicate effectively with all levels of internal/external staff, management, members, physicians/physician office staff.
- Knowledge of generally accepted professional office procedures and processes.
- Ability to use the following general office equipment correctly and safely: desktop computer for data entry and typing, copy machine, scanner, facsimile machine, and telephone equipment.
- Ability to create professional documents using proper grammar and punctuation.
- Ability to handle various situations in a professional manner, always demonstrating excellent customer service and ability to adapt to change.
- Coordinates continuity of care with external healthcare organizations and facilities, including obtaining authorizations for services as directed by the clinical staff.
- Assist with creating and faxing authorizations for DME, HH, IV antibiotics, facility transfers, and other health care needs.
- Participates in Patient-Centered quality improvement initiatives.
- Assist in mailing, sending, and gathering CMS notices from home health agencies and skilled nursing facilities.
- Process Denial Letters while adhering to health plan requirements, CMS, and DHCS.
- Updating and maintaining the most current required Health Plan templates
Benefits
- Medical
- Dental
- Vision
- Paid Time Off (PTO)
- Floating Holiday
- Simple IRA Plan with a 3% Employer Contribution
- Employer Paid Life Insurance
- Employee Assistance Program
